False localizing sign of C1–2 cerebrospinal fluid leak in spontaneous intracranial hypotension

2004 ◽  
Vol 100 (4) ◽  
pp. 639-644 ◽  
Author(s):  
Wouter I. Schievink ◽  
M. Marcel Maya ◽  
James Tourje
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Fluid Collection ◽  
Spontaneous Intracranial Hypotension ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Content Type ◽  
The Mean ◽  
Fluid Collections ◽  
Fine Print

Object. Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak is an important cause of new daily persistent headaches. Spinal neuroimaging is important in the treatment of these patients, particularly when direct repair of the CSF leak is contemplated. Retrospinal C1–2 fluid collections may be noted on spinal imaging and these are generally believed to correspond to the site of the CSF leak. The authors undertook a study to determine the significance of these C1–2 fluid collections. Methods. The patient population consisted of a consecutive group of 25 patients (18 female and seven male) who were evaluated for surgical repair of a spontaneous spinal CSF leak. The mean age of the 18 patients was 38 years (range 13–72 years). All patients underwent computerized tomography myelography. Three patients (12%) had extensive retrospinal C1–2 fluid collections; the mean age of this woman and these two men was 41 years (range 39–43 years). The actual site of the CSF leak was located at the lower cervical spine in these patients and did not correspond to the site of the retrospinal C1–2 fluid collection. Conclusions. A retrospinal fluid collection at the C1–2 level does not necessarily indicate the site of the CSF leak in patients with spontaneous intracranial hypotension. This is an important consideration in the treatment of these patients because therapy may be inadvertently directed at this site.

Recurrent spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study

2003 ◽  
Vol 99 (5) ◽  
pp. 840-842 ◽  
Author(s):  
Wouter I. Schievink ◽  
M. Marcel Maya ◽  
Mary Riedinger
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Surgical Repair ◽  
Csf Leak ◽  
Content Type ◽  
Cerebrospinal Fluid Leaks ◽  
The Mean ◽  
A Prospective Study ◽  
Fine Print

Object. Intracranial hypotension due to a spontaneous spinal cerebrospinal fluid (CSF) leak is an increasingly recognized cause of postural headaches, but reliable follow-up data are lacking. The authors undertook a study to determine the risk of a recurrent spontaneous spinal CSF leak. Methods. The patient population consisted of a consecutive group of 18 patients who had been evaluated for consideration of surgical repair of a spontaneous spinal CSF leak. The mean age of the 15 women and three men was 38 years (range 22–55 years). The mean duration of follow up was 36 months (range 6–132 months). The total follow-up time was 654 months. A recurrent spinal CSF leak was defined on the basis of computerized tomography myelography evidence of a CSF leak in a previously visualized but unaffected spinal location. Five patients (28%) developed a recurrent spinal CSF leak; the mean age of these four women and one man was 36 years. A recurrent CSF leak developed in five (38%) of 13 patients who had undergone surgical CSF leak repair, compared with none (0%) of five patients who had been treated non-surgically (p = 0.249). The recurrent leak occurred between 10 and 77 months after the initial CSF leak, but within 2 or 3 months of successful surgical repair of the leak in all patients. Conclusions. Recurrent spontaneous spinal CSF leaks are not rare, and the recent successful repair of such a leak at another site may be an important risk factor.

Spectrum of subdural fluid collections in spontaneous intracranial hypotension

2005 ◽  
Vol 103 (4) ◽  
pp. 608-613 ◽  
Author(s):  
Wouter I. Schievink ◽  
M. Marcel Maya ◽  
Franklin G. Moser ◽  
James Tourje
Keyword(s):  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Mass Effect ◽  
Csf Leak ◽  
Radiographic Findings ◽  
Content Type ◽  
Fluid Collections ◽  
Significant Mass Effect ◽  
Fine Print ◽  
Significant Mass

Object. Spontaneous intracranial hypotension is a noteworthy but commonly misdiagnosed cause of new daily persistent headaches. Subdural fluid collections are frequent radiographic findings, but they can be interpreted as primary rather than secondary pathological entities, and uncertainties exist regarding their optimal management. The authors therefore reviewed their experience with subdural fluid collections in 40 consecutive patients with spontaneous spinal cerebrospinal fluid (CSF) leaks and intracranial hypotension. Methods. The mean age of the 26 female and 14 male patients was 43 years (range 13–72 years). Subdural fluid collections were present in 20 patients (50%); 12 of these patients (60%) had subdural hygromas alone, and eight (40%) had subacute to chronic subdural hematomas (SDHs) associated with significant mass effect. The subdural hygromas resolved within several days to weeks following treatment of the underlying CSF leak. Three patients with SDHs underwent evacuation of the hematoma prior to the establishment of the diagnosis of spontaneous intracranial hypotension, but the SDHs did not resolve until the underlying spinal CSF leak was treated. In the remaining five patients, the CSF leak was treated primarily and the SDHs resolved over a 1- to 3-month period without the need for evacuation. Conclusions. Subdural fluid collections are common in spontaneous intracranial hypotension, varying in appearance from thin subdural hygromas to large SDHs associated with significant mass effect. These collections can be safely managed by directing treatment at the underlying CSF leak without the need for hematoma evacuation.

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

1996 ◽  
Vol 84 (4) ◽  
pp. 598-605 ◽  
Author(s):  
Wouter I. Schievink ◽  
Fredric B. Meyer ◽  
John L. D. Atkinson ◽  
Bahram Mokri
Keyword(s):  
Cerebrospinal Fluid ◽  
Thoracic Spine ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Cervicothoracic Junction ◽  
Ct Myelography ◽  
Content Type ◽  
Fine Print ◽  
Csf Leaks

✓ Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22–51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.

Surgical treatment of spontaneous intracranial hypotension associated with a spinal arachnoid diverticulum

1994 ◽  
Vol 80 (4) ◽  
pp. 736-739 ◽  
Author(s):  
Wouter I. Schievink ◽  
Ronald Reimer ◽  
W. Neath Folger
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Cerebrospinal Fluid Leak ◽  
Content Type ◽  
Fluid Leak ◽  
Fine Print

✓ The authors present the case of a 22-year-old woman who developed spontaneous intracranial hypotension as a result of a cerebrospinal fluid leak from a thoracic extradural arachnoid diverticulum. The patient was successfully treated by ligation of the diverticulum. The entity of spontaneous intracranial hypotension and its relevance to neurosurgery are discussed.

Acquired Chiari I malformation secondary to spontaneous spinal cerebrospinal fluid leakage and chronic intracranial hypotension syndrome in seven cases

1998 ◽  
Vol 88 (2) ◽  
pp. 237-242 ◽  
Author(s):  
John L. D. Atkinson ◽  
Brian G. Weinshenker ◽  
Gary M. Miller ◽  
David G. Piepgras ◽  
Bahram Mokri
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Chiari I Malformation ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Content Type ◽  
Intracranial Hypotension Syndrome ◽  
Csf Leakage ◽  
Chiari I ◽  
Fine Print

Object. Spontaneous spinal cerebrospinal fluid (CSF) leakage with development of the intracranial hypotension syndrome and acquired Chiari I malformation due to lumbar spinal CSF diversion procedures have both been well described. However, concomitant presentation of both syndromes has rarely been reported. The object of this paper is to present data in seven cases in which both syndromes were present. Three illustrative cases are reported in detail. Methods. The authors describe seven symptomatic cases of spontaneous spinal CSF leakage with chronic intracranial hypotension syndrome in which magnetic resonance (MR) images depicted dural enhancement, brain sagging, loss of CSF cisterns, and acquired Chiari I malformation. Conclusions. This subtype of intracranial hypotension syndrome probably results from chronic spinal drainage of CSF or high-flow CSF shunting and subsequent loss of brain buoyancy that results in brain settling and herniation of hindbrain structures through the foramen magnum. Of 35 cases of spontaneous spinal CSF leakage identified in the authors' practice over the last decade, MR imaging evidence of acquired Chiari I malformation has been shown in seven. Not to be confused with idiopathic Chiari I malformation, ideal therapy requires recognition of the syndrome and treatment directed to the site of the spinal CSF leak.

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

1998 ◽  
Vol 88 (2) ◽  
pp. 243-246 ◽  
Author(s):  
Wouter I. Schievink ◽  
Vittorio M. Morreale ◽  
John L. D. Atkinson ◽  
Fredric B. Meyer ◽  
David G. Piepgras ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Intracranial Hypotension ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Content Type ◽  
Surgical Exploration ◽  
Fine Print ◽  
Csf Leaks

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Intracranial hypotension without meningeal enhancement on magnetic resonance imaging

2000 ◽  
Vol 92 (3) ◽  
pp. 475-477 ◽  
Author(s):  
Wouter I. Schievink ◽  
James Tourje
Keyword(s):  
Magnetic Resonance ◽  
Mr Imaging ◽  
Intracranial Hypotension ◽  
Radiological Feature ◽  
Csf Leak ◽  
Meningeal Enhancement ◽  
Content Type ◽  
Fluid Collections ◽  
Lumbar Cerebrospinal Fluid ◽  
Fine Print

✓ Meningeal enhancement on magnetic resonance (MR) imaging is considered the hallmark radiological feature of intracranial hypotension. The authors report on a patient who exhibited progressively symptomatic intracranial hypotension due to a lumbar cerebrospinal fluid (CSF) leak, but in whom MR imaging demonstrated no pachymeningeal enhancement.This 24-year-old man presented with a 6-week history of progressive orthostatic headaches that were associated with photo- and phonophobia. Four weeks before the onset of the headaches, the patient had undergone a lumbar laminectomy. Brain MR images revealed subdural fluid collections and brain sagging; however, meningeal enhancement was not present. Myelography demonstrated a CSF leak at the site of the laminectomy. At surgery, a large dural tear was repaired. The patient recovered well from the surgery, with complete resolution of his headaches.The absence of meningeal enhancement on MR imaging does not exclude a diagnosis of symptomatic intracranial hypotension.

Cerebral vasospasm following intracranial hypotension caused by cerebrospinal fluid leak from an incidental lumbar durotomy

2005 ◽  
Vol 102 (1) ◽  
pp. 152-155 ◽  
Author(s):  
Claudia Chaves ◽  
Stephen R. Freidberg ◽  
Grace Lee ◽  
Vasilios Zeris ◽  
Sarah Ries ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Cerebral Vasospasm ◽  
Intracranial Hypotension ◽  
Unusual Case ◽  
Cerebrospinal Fluid Leak ◽  
Dural Tear ◽  
Content Type ◽  
Incidental Durotomy ◽  
Fluid Leak ◽  
Fine Print

✓ The authors report on the unusual case of a patient with intracranial hypotension following an incidental durotomy complicated by an extensive but reversible cerebral vasospasm. Despite the dural tear repair and correction of the intracranial hypotension, the vasospasm ran its course. The precise mechanism of the cerebral vasospasm in this patient is unclear.

scholarly journals Spontaneous CSF Collection in the Cervical Spine may Cause Neurological Deficit and Intra-cranial Hypotension

2013 ◽  
Vol 7 (1) ◽  
pp. 1-3 ◽  
Author(s):  
Rasheed Zakaria ◽  
Martin Wilby ◽  
Nicholas A Fletcher
Keyword(s):  
Cerebrospinal Fluid ◽  
Cervical Spine ◽  
Intracranial Hypotension ◽  
Cervical Spinal Cord ◽  
Fluid Collection ◽  
Spontaneous Intracranial Hypotension ◽  
Motor Deficit ◽  
Limb Weakness ◽  
Meningeal Enhancement ◽  
Fluid Collections

Objective:a case is described of a spontaneously occurring cerebrospinal fluid collection in the ventral cervical spine which caused radiculopathy and spontaneous intracranial hypotension. Case:a sixty eight year old Caucasian man presented with a 2 year history of proximal upper limb weakness with a his-tory of trivial cervical trauma many years previously. Methods:the patient was investigated with blood tests for causes of peripheral neuropathy, nerve conduction and electro-myography studies, lumbar puncture and MRI of the brain and spine with contrast. Results:a cerebrospinal fluid collection was identified in the ventral cervical spinal cord causing mass effect associated with cord atrophy and there were signs of spontaneous intracranial hypotension on the MRI brain including subdural cere-brospinal fluid collections, meningeal enhancement and slumped posterior fossa. Conclusions:this is the first description of a spontaneous spinal fluid collection causing direct compression and cord sig-nal change, manifest as a motor deficit, with intracranial signs of spontaneous hypotension. Spinal imaging is recom-mended in cases of spontaneous intracranial hypotension and cerebrospinal fluid collections in the spine may rarely be a cause of radiculopathy in such cases.

Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant

2004 ◽  
Vol 100 (6) ◽  
pp. 1098-1100 ◽  
Author(s):  
Wouter I. Schievink ◽  
M. Marcel Maya ◽  
Franklin M. Moser
Keyword(s):  
Fibrin Sealant ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Invasive Treatment ◽  
Content Type ◽  
Epidural Blood Patching ◽  
Lower Thoracic Spine ◽  
Fine Print ◽  
Csf Leaks

✓ Spontaneous intracranial hypotension due to a cerebrospinal fluid (CSF) leak in the spine is an important cause of new, daily persistent headaches. Most patients respond well to conservative treatments including epidural blood patching. Limited options for effective treatment are available for patients in whom these treatments fail. The authors treated four patients (mean age 38 years; range 26–43 years) with percutaneous placement of a fibrin sealant. All these patients presented with intractable positional headaches. The CSF leak was located in the lower cervical spine in three patients and in the lower thoracic spine in one patient. Four to 20 milliliters of fibrin sealant was injected at the site of the CSF leak. Two of the four patients became asymptomatic within days of the procedure and thus avoided surgery. There were no complications of this procedure. Percutaneous placement of a fibrin sealant is a safe, minimally invasive treatment for spontaneous spinal CSF leaks and should be considered in patients in whom conservative treatment has failed.

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